Variability of the accommodation response in early onset myopia

Purpose. Hyperopic retinal defocus (blur) is thought to be a cause of myopia. If the retinal image of an object is not clearly focused, the resulting blur is thought to cause the continuing lengthening of the eyeball during development causing a permanent refractive error. Both lag of accommodation, especially for near targets, and greater variability in the accommodative response, have been suggested as causes of increased hyperopic retinal blur. Previous studies of lag of accommodation show variable findings. In comparison, greater variability in the accommodative response has been demonstrated in adults with late onset myopia but has not been tested in children. This study looked at the lag and variability of accommodation in children with early onset myopia. Methods. Twenty-one myopic and 18 emmetropic children were tested. Dynamic measures of accommodation and pupil size were made using eccentric photorefraction (Power Refractor) while children viewed targets set at three different accommodative demands (0.25, 2, and 4 D). Results. We found no difference in accommodative lag between groups. However, the accommodative response was more variable in the myopes than emmetropes when viewing both the near (4 D) and far (0.25 D) targets. Since pupil size and variability also varied, we analyzed the data to determine whether this could account for the inter-group differences in accommodation variability. Variation in these factors was not found to be sufficient to explain these differences. Changes in the accommodative response variability with target distance were similar to patterns reported previously in adult emmetropes and late onset myopes. Conclusions. Children with early onset myopia demonstrate greater accommodative variability than emmetropic children, and have similar patterns of response to adult late onset myopes. This increased variability could result in an increase in retinal blur for both near and far targets. The role of accommodative variability in the etiology of myopia is discussed.

Gender differences in early accommodation and vergence development

A remote haploscopic photorefractor was used to assess objective binocular vergence and accommodation responses in 157 full-term healthy infants aged 1-6 months while fixating a brightly coloured target moving between fixation distances at 2, 1, 0.5 and 0.33 m. Vergence and accommodation response gain matured rapidly from 'flat' neonatal responses at an intercept of approximately 2 dioptres (D) for accommodation and 2.5 metre angles(MA) for vergence, reaching adult-like values at 4 months. Vergence gain was marginally higher in females (p = 0.064), but accommodation gain (p = 0.034) was higher and accommodative intercept closer to zero (p = 0.004) in males in the first 3 months as they relaxed accommodation more appropriately for distant targets. More females showed flat accommodation responses (p = 0.029). More males behaved hypermetropically in the first two months of life, but when these hypermetropic infants were excluded from the analysis, the gender difference remained. Gender differences disappeared after three months. Data showed variable responses and infants could behave appropriately and simultaneously on both, neither or only one measure at all ages. If accommodation was appropriate (gain between 0.7 and 1.3; r(2) > 0.7) but vergence was not, males over- and under-converged equally, while the females who accommodated appropriately were more likely to overconverge (p = 0.008). The apparent earlier maturity of the male accommodative responses may be due to refractive error differences but could also reflect gender-specific male preference for blur cues while females show earlier preference for disparity, which may underpin the earlier emerging, disparity dependent, stereopsis and full vergence found in females in other studies.

The development of convergence and accommodation

Aim: To review current literature on the development of convergence and accommodation. The accommodation and vergence systems provide the foundation upon which bifoveal binocular single vision develops. Deviations from their normal development not only are implicated in the aetiology of convergence anomalies, accommodative anomalies and strabismus, but may also be implicated in failure of the emmetropisation process. Method: This review considers the problems of researching the development of accommodation and vergence in infants and how infant research has had to differ from adult methods. It then reviews and discusses the implications of current research into the development of both systems and their linkages. Results: Vergence and accommodation develop rapidly in the first months of life, with accommodation changing from relatively fixed myopic focus in the neonatal period to adult-like responses by 4 months of age. Vergence develops gradually and becomes more accurate after 4 months of age, but has been demonstrated in infants well before the age that binocular disparity detection mechanisms are thought to develop. Hypotheses for this early vergence mechanism are discussed. The relationship between accommodation and vergence shows much more variability in infants than adult literature has found, but this apparent adult/infant difference may be partly attributed to methodological differences rather than maturational change alone. Conclusions: Variability and flexibility characterise infant responses. This variability may enable infants to develop a flexible and robust binocular system for later life. Studies of infant visual cue use may give clues to the aetiology of strabismus and refractive error.

Accommodative instability: relationship to progression of early onset myopia

Background: In a previous study, we demonstrated that children with early onset myopia had greater instability of accommodation than a group of emmetropic children. Since that study was correlational, we were unable to determine the causal relationship between this and myopic progression. To address this, we examined the children two years later. We predicted that if accommodative instability was causing the myopic progression, instability at Visit 1 should predict the refractive error at Visit 2. Additionally, instability at Visit 1 should predict myopic progression. Methods: Thirteen myopic and 16 emmetropic children were included in the analysis. Dynamic measures of accommodation were made using eccentric photorefraction (PowerRefractor) while children viewed targets set at three distances (accommodative demands), namely, 0.25 metres (4.00 D demand), 0.5 metres (2.00 D demand) and 4.00 metres (0.25 D demand). Results: Both refractive error and accommodative instability at Visit 1 were highly correlated with the same measures at Visit 2. Children with myopia showed greater instability of accommodation (0.38 D) than children with emmetropia (0.26 D) at the 4.00 D target on Visit 1 and this instability of accommodation weakly predicted myopic progression. Conclusions: The results presented in the present study suggest that instability of accommodation accompanies myopic progression, although a casual relationship cannot be established.

Accommodation and vergence response gains to different near cues characterize specific esotropias

Aim. To describe preliminary findings of how the profile of the use of blur, disparity and proximal cues varies between non-strabismic groups and those with different types of esotropia. Design. Case control study Methodology. A remote haploscopic photorefractor measured simultaneous convergence and accommodation to a range of targets containing all combinations of binocular disparity, blur and proximal (looming) cues. 13 constant esotropes, 16 fully accommodative esotropes, and 8 convergence excess esotropes were compared with age and refractive error matched controls, and 27 young adult emmetropic controls. All wore full refractive correction if not emmetropic. Response AC/A and CA/C ratios were also assessed. Results. Cue use differed between the groups. Even esotropes with constant suppression and no binocular vision (BV) responded to disparity in cues. The constant esotropes with weak BV showed trends for more stable responses and better vergence and accommodation than those without any BV. The accommodative esotropes made less use of disparity cues to drive accommodation (p=0.04) and more use of blur to drive vergence (p=0.008) than controls. All esotropic groups failed to show the strong bias for better responses to disparity cues found in the controls, with convergence excess esotropes favoring blur cues. AC/A and CA/C ratios existed in an inverse relationship in the different groups. Accommodative lag of >1.0D at 33cm was common (46%) in the pooled esotropia groups compared with 11% in typical children (p=0.05). Conclusion. Esotropic children use near cues differently from matched non-esotropic children in ways characteristic to their deviations. Relatively higher weighting for blur cues was found in accommodative esotropia compared to matched controls.

Estrabismo: detecção em uma amostra populacional e fatores demográficos associados

OBJETIVOS: Identificar a frequência de ocorrência de desvios oculares e as características dos portadores em uma amostra populacional. MÉTODOS: Estudo transversal, observacional e probabilístico, entre os anos de 2004 e 2005, envolvendo 11 cidades da região centro-oeste do estado de São Paulo. Foram examinados 10.994 indivíduos, sendo utilizada para este estudo uma subamostra desta população, identificada pelo diagnóstico de estrabismo. A população foi abordada por uma equipe treinada e padronizada para os procedimentos da pesquisa. Os dados foram analisados estatisticamente por meio de análise descritiva, frequência de ocorrência, análise de contingência e testes de associação (p<0,05). RESULTADOS: A frequência de ocorrência de estrabismo na população estudada foi de 1,4% (148 portadores de estrabismo), sem diferença entre sexos. Portadores de esodesvios (ET) eram 46,3%, 38,2% casos de exodesvio (XT) e 15,4% de desvios verticais associados a horizontais ou síndromes. A análise de contingência mostrou que 3 indivíduos (2,3%) estrábicos apresentavam cegueira e 7 (5,43%) apresentavam baixa visão em um dos olhos. Tanto a ET, quanto a XT estiveram presentes em indivíduos com graus variáveis de miopia (até -5,75 para XT e -2,50 para ET) e de hipermetropia (até +9,00 para XT e +8,00 para ET). A associação entre estrabismo e o equivalente esférico obtido na refração estática não mostrou diferença significativa (p>0,05). CONCLUSÃO: A frequência de ocorrência de estrabismo em uma amostra populacional foi de 1,4%, sem diferença entre sexos ou tipo de desvio ocular. A presença de cegueira e de baixa visão associadas aos desvios oculares reforçam a necessidade de tratamento precoce.

Erros de refração como causas de baixa visual em crianças da rede de escolas públicas da regional de Botucatu - SP

OBJETIVO: Estudar a ocorrência dos erros refracionais em escolares de nosso meio. MÉTODOS: Estudo transversal avaliando crianças da pré-escola e do ensino básico, quanto ao sexo, tipo de erro refracional, acuidade visual e tratamento realizado. RESULTADOS: Quatro mil seiscentos e vinte e três crianças foram submetidas a exame de acuidade visual, das quais 8,1% apresentaram necessidade de exame oftalmológico completo. Houve 63,2% de portadores de astigmatismo hipermetrópico, 15,7% de astigmatismo miópico, 12,5% de astigmatismo misto, 4,9% de hipermetropia e 3,7% de miopia. Foi indicada a prescrição de lentes corretoras para 48,7% da amostra estudada. A frequência de erros refracionais na população foi de 3,9%. CONCLUSÃO: O astigmatismo hipermetrópico foi o erro de refracional mais frequente, havendo necessidade de tratamento em cerca de 50% das crianças triadas com frequência de 3,9% de erro refracional passível de correção na população de estudo.

Condição ocular dos indivíduos facectomizados na região centro-oeste do estado de São Paulo: estudo populacional

OBJETIVO: Avaliar as causas de baixa visão e cegueira em indivíduos facectomizados, de amostra da população de cidades da região centrooeste do estado de São Paulo. Métodos: Estudo transversal, observacional, feito em cinco cidades da região centro-oeste do estado de São Paulo, em amostra domiciliar e baseada nos dados do último Censo Demográfico (IBGE, 1995), com escolha sistemática dos domicílios. Foi considerada para o presente estudo uma subamostra de indivíduos facectomizados, dos quais foram obtidos dados de identificação e exame oftalmológico completo. Os dados foram avaliados por estatísticas descritivas, análise de freqüência de ocorrência e proporção de concordância, com intervalo de confiança de 95%. RESULTADOS: Dos indivíduos amostrados, 2,37% haviam sido submetidos à facectomia. Dos 201 olhos operados, 26,9% apresentavam acuidade visual compatível com cegueira ou deficiência visual. Com a melhor correção óptica, a acuidade visual permaneceu <0,3 em 19,0%. O exame refracional proporcionou melhora da acuidade visual para 27,9% dos indivíduos facectomizados. As causas de baixa visão foram os erros refrativos não corrigidos, opacidade de cápsula posterior (19,4%), ceratopatia bolhosa (8,3%) coriorretinite cicatricial (8,3%), afacia (8,3%), degeneração macular relacionada a idade (5,5%), leucoma (5,5%), glaucoma (5,5%), atrofia de papila (5,5,%), descolamento de retina (2,8%), atrofia de epitelio pigmentado da retina (2,8%) e alta miopia (2,8%). CONCLUSÃO: Apesar da catarata ser causa de cegueira que pode ser evitável, mesmo após a correção cirúrgica porcentagem expressiva de indivíduos permanece com baixa visão, em geral, em decorrência de fatores relacionados ao seguimento pós-operatório negligenciado.

Prevalence and causes of visual impairment in a Brazilian population: The Botucatu Eye Study

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

A Method for Assessing the Sustainability of Design in Developing World Projects

Projects for the developing world usually find themselves at the bottom of an engineer’s priority list. There is often very little engineering effort placed on creating new products for the poorest people in the world. This trend is beginning to change now as people begin to recognize the potential for these projects. Engineers are beginning to try and solve some of the direst issues in the developing world and many are having positive impacts. However, the conditions needed to support these projects can only be maintained in the short term. There is now a need for greater sustainability. Sustainability has a wide variety of definitions in both business and engineering. These concepts are analyzed and synthesized to develop a broad meaning of sustainability in the developing world. This primarily stems from the “triple bottom line” concept of economic, social, and environmental sustainability. Using this model and several international standards, this thesis develops a metric for guiding and evaluating the sustainability of engineering projects. The metric contains qualitative questions that investigate the sustainability of a project. It is used to assess several existing projects in order to determine flaws. Specifically, three projects seeking to deliver eyeglasses are analyzed for weaknesses to help define a new design approach for achieving better results. Using the metric as a guiding tool, teams designed two pieces of optometry equipment: one to cut lenses for eyeglasses and the other to diagnose refractive error, or prescription. These designs are created and prototyped in the developed and developing worlds in order to determine general feasibility. Although there is a recognized need for eventual design iterations, the whole project is evaluated using the developed metric and compared to the existing projects. Overall, the success demonstrates the improvements made to the long-term sustainability of the project resulting from the use of the sustainability metric.

Choroidal Thickness And Volume In Healthy Young Whites And Their Relationship With Axial Length, Ammetropy And Sex

Purpose: To evaluate choroidal thickness in young subjects using Enhanced Depth Imaging Spectral Domain Optical Coherence Tomography (EDI SD-OCT) describing volume differences between all the defined areas of the Early Treatment Diabetic Retinopathy Study (ETDRS). Design: Prospective, clinical study. Methods: Seventy-nine eyes of 95 healthy, young (23.8±3.2years), adult volunteers were prospectively enrolled. Manual choroidal segmentation on a 25-raster horizontal scan protocol was performed. The measurements of the nine subfields defined by the ETDRS were evaluated. Results: Mean subfoveal choroidal thickness was 345.67±81.80μm and mean total choroidal volume was 8.99±1.88mm3. Choroidal thickness and volume were higher at the superior and temporal areas compared to inferior and nasal sectors of the same diameter respectively. Strong correlations between subfoveal choroidal thickness and axial length (AL) and myopic refractive error were obtained, r = -0.649, p<0.001 and r = 0.473, p<0.001 respectively. Emmetropic eyes tended to have thicker subfoveal choroidal thickness (381.94±79.88μm versus 307.04±64.91μm) and higher total choroidal volume than myopic eyes (9.80± 1.87mm3 versus 8.14±1.48mm3). The estimation of the variation of the subfoveal choroidal thickness with the AL was-43.84μm/mm. In the myopic group, the variation of the subfoveal choroidal thickness with the myopic refractive error was -10.45μm/D. Conclusions: This study establishes for the first time a normal database for choroidal thickness and volume in young adults. Axial length, and myopic ammetropy are highly associated with choroidal parameters in healthy subjects. EDI SD-OCT exhibited a high degree of intraobserver and interobserver repeatability.

Visual and optical performance and quality of life after implantation of posterior chamber phakic intraocular lens

Purpose To evaluate visual, optical, and quality of life (QoL) outcomes and intercorrelations after bilateral implantation of posterior chamber phakic intraocular lenses. Methods Twenty eyes with high to moderate myopia of 10 patients that underwent PRL implantation (Phakic Refractive Lens, Carl Zeiss Meditec AG) were examined. Refraction, visual acuity, photopic and low mesopic contrast sensitivity (CS) with and without glare, ocular aberrations, as well as QoL outcomes (National Eye Institute Refractive Error Quality of Life Instrument-42, NEI RQL-42) were evaluated at 12 months postoperatively. Results Significant improvement in uncorrected (UDVA) and best-corrected distance (CDVA) visual acuities were found postoperatively (p < 0.01), with significant reduction in spherical equivalent (p < 0.01). Low mesopic CS without glare was significantly better than measurements with glare for 1.5, 3, and 6 cycles/degree (p < 0.01). No significant correlations between higher order root mean square (RMS) with CDVA (r = −0.26, p = 0.27) and CS (r ≤ 0.45, p ≥ 0.05) were found. Postoperative binocular photopic CS for 12 cycles/degree and 18 cycles/degree correlated significantly with several RQL-42 scales. Glare index correlated significantly with CS measures and scotopic pupil size (r = −0.551, p = 0.04), but not with higher order RMS (r = −0.02, p = 0.94). Postoperative higher order RMS, postoperative primary coma and postoperative spherical aberration was significant higher for 5-mm pupil diameter (p < 0.01) compared with controls. Conclusions Correction of moderate to high myopia by means of PRL implantation had a positive impact on CS and QoL. The aberrometric increase induced by the surgery does not seem to limit CS and QoL. However, perception of glare is still a relevant disturbance in some cases possibly related to the limitation of the optical zone of the PRL.

The effect of manipulations to target contrast on emmetropization in chick

Emmetropization is dependent on visual feedback and presumably some measure of the optical and image quality of the eye. We investigated the effect of simple alterations to image contrast on eye growth and refractive development. A 1.6 cyc/deg square-wave-grating target was located at the end of a 3.3 cm cone,, imaged by a +30 D lens and applied monocularly to the eyes of 8-day-old chicks. Eleven different contrast targets were tested: 95, 67, 47.5, 33.5, 24, 17, 12, 8.5, 4.2, 2.1, and 0%. Refractive error (RE), vitreous chamber depth (VC) and axial length (AL) varied with the contrast of the image (RE diff. F-10.86 = 12.420, p < 0.0005; VC diff. F-10.86 = 8.756, p < 0.0005; AL diff. F-10.86 = 9.240, p < 0.0005). Target contrasts 4.2% and lower produced relative myopia (4.2%: RE diff = -7.48 +/- 2.26 D, p = 0.987; 2.1%: RE diff = -7.22 +/- 2.77 D, p = 0.951) of similar amount to that observed in response to a featureless 0% contrast target (RE diff = -9.11 +/- 4.68 D). For target contrast levels 47.5% and greater isometropia was maintained (95%: RE diff = 1.83 +/- 2.78 D; 67%: RE diff = 0.14 +/- 1.84 D; 47.5% RE diff = 0.25 +/- 1.82 D). Contrasts in between produced an intermediate amount of myopia (33.5%: RE diff = -2.81 +/- 1.80 D; 24%: RE diff = -3.45 +/- 1.64 D; 17%: RE diff = -3.19 +/- 1.54 D; 12%: RE diff = -4.08 +/- 3.56 D; 8.5%: RE diff = -4.09 +/- 3.60 D). We conclude that image contrast provides important visual information for the eye growth control system or that contrast must reach a threshold value for some other emmetropization signal to function. (c) 2005 Elsevier Ltd. All rights reserved.

Clinical evaluation of the Shin-Nippon NVision-K 5001/Grand Seiko WR-5100K autorefractor

Purpose. A clinical evaluation of the Shin-Nippon NVision-K 5001 (also branded as the Grand Seiko WR-5100K) autorefractor (Japan) was performed to examine validity and repeatability compared with subjective refraction and Javal-Schiotz keratometry. Methods. Measurements of refractive error were performed on 198 eyes of 99 subjects (aged 23.2 ± 7.4 years) subjectively (noncycloplegic) by one masked optometrist and objectively with the NVision-K autorefractor by a second optometrist. Keratometry measurements using the NVision-K were compared with the Javal-Schiotz keratometer. Intrasession repeatability of the NVision-K was also assessed on all 99 subjects together with intersession repeatability on a separate occasion separated by 7 to 14 days. Results. Refractive error as measured by the NVision-K was found to be similar (p = 0.67) to subjective refraction (difference, 0.14 ± 0.35 D). It was both accurate and repeatable over a wide prescription range (-8.25 to +7.25 D). Keratometry as measured by the NVision-K was found to be similar (p > 0.50) to the Javal-Schiotz technique in both the horizontal and vertical meridians (horizontal: difference, 0.02 ± 0.09 mm; vertical: difference, 0.01 ± 0.14 mm). There was minimal bias, and the results were repeatable (horizontal: intersession difference, 0.00 ± 0.09 mm; vertical: intersession difference, -0.01 ± 0.12 mm). Conclusion. The open-view arrangement of the Shin-Nippon NVision-K 5001 facilitates the measurement of static refractive error and the accommodative response to real-world stimuli. Coupled with its accuracy, repeatability, and capability to measure corneal curvature, it is a valuable addition to objective instrumentation currently available to the optometrist and researcher.

Childhood ethnic differences in ametropia and ocular biometry:the Aston Eye Study

Purpose: To describe the methodology, sampling strategy and preliminary results for the Aston Eye Study (AES), a cross-sectional study to determine the prevalence of refractive error and its associated ocular biometry in a large multi-racial sample of school children from the metropolitan area of Birmingham, England. Methods: A target sample of 1700 children aged 6–7 years and 1200 aged 12–13 years is being selected from Birmingham schools selected randomly with stratification by area deprivation index (a measure of socio-economic status). Schools with pupils predominantly (>70%) from a single race are excluded. Sample size calculations account for the likely participation rate and the clustering of individuals within schools. Procedures involve standardised protocols to allow for comparison with international population-based data. Visual acuity, non-contact ocular biometry (axial length, corneal radius of curvature and anterior chamber depth) and cycloplegic autorefraction are measured in both eyes. Distance and near oculomotor balance, height and weight are also assessed. Questionnaires for parents and older children will allow the influence of environmental factors on refractive error to be examined. Results: Recruitment and data collection are ongoing (currently N = 655). Preliminary cross-sectional data on 213 South Asian, 44 black African Caribbean and 70 white European children aged 6–7 years and 114 South Asian, 40 black African Caribbean and 115 white European children aged 12–13 years found myopia prevalence of 9.4% and 29.4% for the two age groups respectively. A more negative mean spherical equivalent refraction (SER) was observed in older children (-0.21 D vs +0.87 D). Ethnic differences in myopia prevalence are emerging with South Asian children having higher levels than white European children 36.8% vs 18.6% (for the older children). Axial length, corneal radius of curvature and anterior chamber depth were normally distributed, while SER was leptokurtic (p < 0.001) with a slight negative skew. Conclusions: The AES will allow ethnic differences in the ocular characteristics of children from a large metropolitan area of the UK to be examined. The findings to date indicate the emergence of higher levels of myopia by early adolescence in second and third generation British South Asians, compared to white European children. The continuation of the AES will allow the early determinants of these ethnic differences to be studied.